Correct coding for any surgical service provided in an ASC is critical to ensuring proper reimbursement, reducing denials and avoiding potential compliance issues. One could argue that the stakes are even higher when the service is far and away the most frequently provided service in ASCs, with even small errors having potentially large implications on a facility's bottom line.
Such is the case for cataract surgery. According to data from the Medicare Payment Advisory Commission (MedPAC), in its March 2018 "Report to the Congress: Medicare Payment Policy," cataract surgery (with intraocular lens (IOL) insert, 1 stage) accounted for 18.7% of 2016 surgical volume in ASCs — more than double the next most frequent service.
Follow these eight dos and don'ts to help ensure your ASC consistently receives timely, proper payment for cataract procedures.
Avoid "Complex" Assumptions
1. Don't assume that because providers state they performed a "complex" cataract extraction that you should use CPT code 66982, defined as Extra capsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage.
2. Do familiarize yourself with the American Medical Association's (AMA's) guidelines for what constitutes a complex cataract removal and your state's local coverage determination (LCD) requirements, which may differ.
The challenge concerning properly coding complex cataract extraction is that what constitutes a complex cataract can now differ between AMA guidelines and various LCDs. For a long time, the common practice was to follow what the AMA's CPT Assistant newsletter explained was necessary to constitute a complex cataract. However, there is now a potential difference in opinion between the AMA and Medicare on complex cataract requirements. Since carrier rules trump AMA's recommendations, it is vital that you determine your state's specific requirements for complexity.
This is an area under scrutiny by the Office of Inspector General, making it important for ASCs to ensure they understand the proper guidelines to follow when coding for complex cataracts.
Ignore Patient's Age
3. Don't automatically code cataracts as age-related based on the patient's age.
4. Do communicate with providers about the need to document the specific type of cataract.
While it might be tempting to code a cataract as "senile" just because a patient is more than 70 years old, doing so would be incorrect. If a physician did not indicate cataract type (e.g., age-related, senile, diabetic), you would be expected to use the code for unspecified cataract.
That's why the devil here is in the details. If a physician does not indicate the specific cataract type used, send the documentation back and require this information. It's the appropriate way to accurately code the procedure.
Get Paid for Specialty IOLs
5. Don't lose money on specialty IOLs.
6. Do verify if your carriers will reimburse for them or collect money from your patients up front.
It's not uncommon for ASCs to provide specialty IOLs but never receive payment for them. All this does is unnecessarily cut into the profitability of a procedure. There is Medicare reimbursement attached to a number of specialty lenses from several manufacturers (more information available here).
ASCs should first verify with their carriers whether there is an allowance for the lens instead of assuming payment is unavailable. If no allowance is available, an ASC would be justified to bill patients for the cost of the lens, preferably collecting that payment prior to the procedure. Note:Make sure to inform patients prior to scheduling their procedure about any potential financial responsibility for their lens to reduce the likelihood of cancellation.
Keep Aqueous Drainage Devices Separate
7. Don't code "iStent" or "CyPass" insertions with a cataract diagnosis.
8. Do familiarize yourself on what these procedures treat and when/how to code them separately from cataract extractions.
"iStent" and "CyPass" are aqueous drainage devices. iStent creates a bypass through the trabecular meshwork from the anterior chamber, while CyPass leads aqueous from the anterior chamber to the supraciliary and then suprachoroidal space. There is often an assumption that you link the use of these devices to a cataract diagnosis. This is incorrect. Doing so should get claims denied as there's no medical necessity for an iStent or CyPass for cataracts.
The reason: Their devices are specific to the treatment of glaucoma. Therefore, they need to be captured separately. Many ASCs encounter claims problems here because of diagnosis linking.
Note: CPT codes copyright American Medical Association
Mandeara Frye (firstname.lastname@example.org) is assistant director of coding and auditing for Surgical Notes. Surgical Notes is a nationwide provider of revenue cycle solutions, including, transcription, coding, revenue cycle management, and document management applications for the ASC and surgical hospital markets.